Chapter 57 The Child With Alterations in Skin Integrity

6) Which is the priority nursing diagnosis when planning care for an infant who is diagnosed with a severe case of oral thrush (Candida albicans)? 1. Ineffective Infant Feeding Pattern related to discomfort 2. Ineffective Breathing Pattern related to oral thrush 3. Activity Intolerance related to oral thrush 4. Ineffective Airway Clearance related to mucus

1. An infant with oral thrush might refuse to nurse or feed because of discomfort and pain. Prompt treatment is necessary so the infant can resume a normal feeding pattern. ild and family.

14) Which parental statement regarding preventative strategies for insect bites and stings indicate the need for further education? 1. "If my child wears bright colors and floral prints when outdoors, she will blend in with the surroundings, and the stinging insects will not sting her." 2. "We should remove any items with standing water from our yard and surrounding area to prevent mosquito reproduction." 3. "My child can use insect repellent containing DEET of 10% or less." 4. "My child should avoid heavy colognes, perfumes, and soaps so that insects are not attracted to them."

1. Bright-colored clothing and floral prints attract the insects. White and light-colored clothing should be worn. This statement requires clarification.

1) Which is the most likely cause for a bright red perianal inflammation with scaly plaques and small papules noted by the nurse during the assessment of a 12-month-old infant? 1. Candida albicans (yeast) 2. Impetigo (staphylococcus) 3. Infrequent diapering 4. Urine and feces

1. Candida albicans is frequently the underlying cause of severe diaper rash. When a primary or secondary infection with C. albicans occurs, the rash has bright red, scaly plaques with sharp margins. Small papules and pustules might be seen, along with satellite lesions.

10) Which is the priority nursing diagnosis during the acute phase of a third-degree circumferential burn of the right arm for a pediatric client? 1. Altered Tissue Perfusion, Risk for 2. Infection, Risk for 3. Impaired Physical Mobility 4. Altered Nutrition: Less than Body Requirements, Risk for

1. Circumferential burns can restrict blood flow due to edema, resulting in tissue hypoxia. Altered Tissue Perfusion to the extremity is the greatest risk and therefore the priority diagnosis.

20) Which is the priority nursing intervention for a 4-year-old client brought to the emergency department (ED) for treatment of frostbite? 1. Administer analgesics. 2. Immerse the hands in extremely warm water (120°F). 3. Do not remove clothing. 4. Place the extremity in a dependent position.

1. Nursing interventions for frostbite include removing wet clothing, using mildly warm water (at 100 to 104°F) to warm the extremity, administering analgesics to decrease pain of the rewarming process, and raising the affected extremity to improve venous return.

7) Which parental statement indicates to the nurse accurate understanding regarding the care of their child with tinea capitis (ringworm of the scalp)? 1. "We will give the griseofulvin with milk or peanut butter." 2. "We're glad ringworm isn't transmitted from person to person." 3. "Once the lesion is gone, we can stop the griseofulvin." 4. "Well, at least we don't have to worry about the family cat getting the ringworm."

1. Parents are advised to give oral griseofulvin with fatty foods such as milk or peanut butter to enhance absorption.

9) Which should the nurse include in the plan of care for a child with a minor burn to enhance nutrition and healing? 1. Protein 2. Minerals 3. Carbohydrates 4. Fats

1. Parents should be taught that management of a minor burn requires a high-calorie, high-protein diet. This is necessary to meet the increased nutritional requirements of healing.

8) Which nursing action is accurate when applying a 5% permethrin lotion to a toddler with scabies? 1. Applying the lotion to the scalp, forehead, and everywhere below the chin 2. Applying the lotion only on the areas with evidence of activity 3. Applying the lotion only to the hands 4. Applying the lotion only to the scalp only

1. Treatment of scabies involves application of a scabicide, such as 5% permethrin lotion, over the entire body from the chin down. The scabicide is also applied to the scalp and forehead of younger children, avoiding the rest of the face.

3) The 10-year-old child is admitted to the hospital following an accident at school that resulted in a puncture wound of the abdomen. Two days after the injury, the child continues in the inflammation phase of healing. What would the nurse expect to see while changing the child's dressing and assessing the wound? 1. The wound is contracting, and the edges are growing together. 2. A blood clot has formed, sealing the wound. 3. Epithelial cells are growing into the wound. 4. The wound is pale and weepy.

2. Clot formation to seal the wound with fibrin and trapped cells and platelets occurs during the inflammation phase of wound healing, in the first 3 to 5 days.

12) The nurse explains to the parents of a child with a severe burn that wearing an elastic pressure garment (Jobst stocking) during the rehabilitative stage can help prevent which complication? 1. Pain 2. Hypertrophic scarring 3. Poor circulation 4. Formation of thrombus in the burn area

2. During the rehabilitation stage, Jobst stockings, or pressure garments, are used to reduce development of hypertrophic scarring and contractures.

13) Which is the priority nursing action when providing care to a child who is bitten by a snake? 1. Measuring the circumference of the extremity twice per hour 2. Monitoring respiratory status 3. Assessing vital signs 4. Evaluating response to pain medication

2. Emergency intervention for airway, breathing, and circulation takes priority and has a high probability of occurrence.

17) Which adolescent statement regarding skin care and acne prevention would indicate the need for further education by the nurse? 1. "I shouldn't squeeze my blackheads or pimples." 2. "I need to watch my diet and cut out all chocolates." 3. "I should avoid applying drying materials, such as astringents, to my face" 4. "I should wash my hands frequently and avoid touching my face."

2. There has been no research that connects diet to acne. A healthy diet with protein is recommended, but chocolate does not have to be excluded. This statement needs to be clarified.

18) Which clinical therapy should the nurse anticipate when planning care for a toddler-age client who is admitted to the hospital unit with cellulitis of the neck? 1. Topical antibiotics 2. Intravenous antibiotics 3. Incision and drainage 4. Oral corticosteroids

2. This infection usually requires parenteral antibiotics.

15) Which discharge instruction is appropriate for an adolescent client who is a paraplegic due to a motor vehicle accident, in order to prevent decubitus ulcer formation on the buttock? 1. Contract the muscles 5 times every 2 hours. 2. Increase fat in the diet to provide a protective coating over the bony prominences. 3. Do wheelchair push-ups every 15 to 30 minutes. 4. Avoid use of sheepskin, as it prevents air from reaching the area.

3. Lifting the buttocks with the arms can help with blood flow to the buttocks and reduce the risk of breakdown.

2) Which finding noted by the school nurse while conducting pediculosis capitis (head lice) checks would indicate the need for treatment? 1. White, flaky particles throughout the entire scalp region 2. Lesions on the scalp that extend to the hairline or neck 3. Maculopapular lesions behind the ears 4. Silver/white sacs attached to the hair shafts in the occipital area

4. Evidence of pediculosis capitis includes silver/white sacs (nits) that are attached to the hair shafts, frequently in the occiput area.

11) The toddler pulled a pot of boiling water off the stove and suffered partial- and full-thickness burns to the chest. The child is now in the recovery-management phase of burn treatment. Which common complication should the nurse assess this client for based on the current data? 1. Asphyxia 2. Metabolic acidosis 3. Shock 4. Wound infection

4. Infection of the burned area is a frequent complication in the recovery-management phase. A goal of burn-wound care is protection from infection.

5) Which is the priority intervention when planning care for an infant who is diagnosed with eczema? 1. Applying antibiotics to lesions 2. Keeping the baby content 3. Maintaining adequate nutrition 4. Preventing infection of lesions

4. Nursing care should focus on preventing infection of lesions. Due to impaired skin barrier function and cutaneous immunity, an infant with eczema is at greater risk for the development of skin infections by organisms.

25) Which topics should be included in a teaching session with parents of school-age children to prevent frostbite? Select all that apply. 1. Dressing in layers 2. Having extra clothing available 3. Removing wet gloves immediately 4. Applying sunscreen twice per day 5. Wearing sunglasses while outside

Answer: 1, 2, 3 Explanation: 1. Dressing in layers is a topic the nurse should include in the teaching session with parents of school-age children to prevent frostbite. 2. Having extra clothing available is a topic the nurse should include in the teaching session with parents of school-age children to prevent frostbite. 3. Removing wet gloves immediately is a topic the nurse should include in the teaching session with parents of school-age children to prevent frostbite.

22) Which pain interventions should the nurse include in the plan of care for a pediatric client who suffered a full-thickness burn injury? Select all that apply. 1. Using an age-appropriate assessment scale 2. Covering the affected skin as much as possible 3. Providing analgesics prior to wound care 4. Keeping the skin as clean and dry as possible 5. Clipping hair around the wound

Answer: 1, 2, 3 Explanation: 1. Pain assessment with an age-appropriate scale is an appropriate intervention for the nurse to include in the plan of care for a client with a full-thickness burn injury. 2. Covering the affected area to prevent temperature changes and air movement is an appropriate intervention for the nurse to include in the plan of care for a client with a full-thickness burn injury. 3. Analgesics administration prior to wound care is an appropriate intervention for the nurse to include in the plan of care for a client with a full-thickness burn injury.

24) Which topics should be included in a teaching session with parents of school-age children to prevent sunburn? Select all that apply. 1. Playing in the shade 2. Wearing a hat while outdoors 3. Restricting outside activities between 10 a.m. and 2 p.m. 4. Using sunscreen with an SPF of 30 or higher 5. Avoiding sunglasses

Answer: 1, 2, 4 Explanation: 1. The nurse should recommend that school-age children play in the shade while outdoors to decrease the risk for sunburn. 2. The nurse should recommend that school-age children wear a hat while outdoors to decrease the risk for sunburn. 4. The nurse should recommend that school-age children use sunscreen with an SPF of 30 or higher to decrease the risk for sunburn.

19) Which preventative strategies for tinea pedis, a fungal infection, also known as athlete's foot, should the nurse include in a teaching session for an adolescent client? Select all that apply. 1. Wear 100% white cotton socks, changed twice a day. 2. Use talc on feet daily. 3. Use an over-the-counter corticosteroid cream to treat the area. 4. Wear foot covers such as flip flops in the locker room and shower. 5. Apply heat to the area twice a day.

Answer: 1, 2, 4 Explanation: 1. The socks will wick moisture away from the feet to promote healing. 2. This process will help keep the feet dry. 4. This will reduce the spread of the organism among team members.

4) A child had an appendectomy and was discharged home at 48 hours postoperative. A week later, the child is readmitted for delayed wound healing. Which causes of delayed wound healing will the nurse review prior to assessing the child? Select all that apply. 1. Infection 2. Predisposing chronic condition, such as diabetes 3. Hypervolemia 4. Inadequate nutrition 5. Hypoxemia

Answer: 1, 2, 4, 5 Explanation: 1. Infection can affect healing and cause excessive scarring. 2. Conditions such as diabetes affect circulating blood volume and are known to affect healing. 4. Poor nutrition without proper protein and calorie intake will affect healing. 5. Hypoxemia makes tissues susceptible to infection due to insufficient oxygenation.

16) Which skin conditions should the nurse identify as having a genetic or inherited component during a presentation to the staff nurses who work in the integument clinic? Select all that apply. 1. Atopic dermatitis 2. Seborrheic dermatitis 3. Epidermolysis bullosa 4. Molluscum contagiosum 5. Psoriasis

Answer: 1, 3, 5 Explanation: 1. Atopic dermatitis is an allergic skin disorder. Allergies have an inherited component. 3. Epidermolysis bullosa is inherited either as autosomal dominant or autosomal recessive depending on type. 5. Psoriasis is usually seen in clients with a family history. A multifactorial inheritance is suspected.

MNL Learning Outcome: 4.3.3. Apply the nursing process in providing care for the child and family. 21) Which adolescent statements indicate the need for further education related to the prevention and treatment of acne? Select all that apply. 1. "I should wash my face each day with an approved cleanser." 2. "I should wash my hands frequently and avoid touching my face." 3. "I should stay away from greasy foods, such as pizza." 4. "I should shampoo my hair only once per week." 5. "I should use my topical medication only when acne is present."

Answer: 3, 4, 5 Explanation: 3. There is no evidence to suggest that greasy foods, such as pizza, cause acne. This statement indicates the need for further education. 4. Hair should be shampooed frequently, as the oil hair can cause acne. This statement indicates the need for further education. 5. Prescribed topical medication should be used daily and spread over the entire face. This statement indicates the need for further education.

23) Which interventions should the nurse include in the plan of care for a pediatric client who suffered a full-thickness burn injury to decrease the risk for infection? Select all that apply. 1. Using an age-appropriate assessment scale 2. Covering the affected skin as much as possible 3. Providing analgesics prior to wound care 4. Keeping the skin as clean and dry as possible 5. Clipping hair around the wound

Answer: 4, 5 Explanation: 4. Keeping the skin as clean and dry as possible is an appropriate intervention to decrease infection. 5. Clipping hair around the wound is an appropriate intervention to decrease infection.